Provider Demographics
NPI:1871273979
Name:FUENTES, ELISA DALI (OTR/L)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:DALI
Last Name:FUENTES
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4033 HARTLAND ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-6095
Mailing Address - Country:US
Mailing Address - Phone:404-661-7784
Mailing Address - Fax:
Practice Address - Street 1:1563 SAM RITTENBERG BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4248
Practice Address - Country:US
Practice Address - Phone:843-277-2411
Practice Address - Fax:855-504-4089
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7679225X00000X
225XG0600X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology